Do We Still Need Fluoroscopy for Adult Transcatheter Atrial Septal Defect Closure?: New Interventionist Perspective in Single Center Experience

Tóm tắt

Background

Transcatheter closure is the treatment of choice for atrial septal defect (ASD); it has good efficacy and relatively safe when the anatomy is suitable. It is preferred method due to the low morbidity, prevention of sternotomy, faster recovery, and reduced length of hospital stay and costs. However, fluoroscopy guiding with this method might have been an issue for the young patients in full reproductive age, due to the development of malignancy. A novel ASD closure technique without fluoroscopy and guided by transesophageal echocardiography (TEE) only to minimize radiation exposure has been introduced and showed good safety in experienced centre. This case series described our relatively new experience in doing transcatheter closure in adult ASD.

Methods

We prospectively performed adult (age >18 years old) interventional ASD closure at Prof IGNG Ngoerah hospital Denpasar (single centre) since September 2022 to August 2023. All patients have diagnosed with isolated secundum ASD based on medical history, clinical signs, chest X-rays, electrocardiograms, transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). Pertinent data including ASD locations, numbers, sizes, morphology, dimensions and rims surrounding the ASD were carefully assessed. Rims assessment with TEE including length, thickness and redundancy of inferior caval vein (IVC) rim, superior caval vein (SVC) rim, aortic rim, posterior rim and mitral valve rim. Deficient or minimal rim defined as less than 5 mm-long. Patient with evidences of pulmonary hypertension, severe tricuspid regurgitation, and left ventricular (LV) systolic dysfunction would undergo cardiac catheterization prior to device closure.

Results

We have performed 20 transcatheter ASD closure during the observation period. 4 cases (20%) had full fluoroscopy ASD closure due to requirement to assess haemodynamic status and cardiac catheterization in cases of pulmonary hypertension. 16 cases of purposely zero fluoroscopy method, 12 cases (75%) was successfully done with mean procedural time of 37 minutes; 4 cases (25%) converted to fluoroscopy due to technical difficulties and challenging anatomy . We have 2 failed case, one due to severe malalignment atrial septum and another case due to complex multi-fenestrated anatomy, extremely thin and floppy atrial septum with embolization of device to the aortic arch. Complications rate was low and procedure time was comparable to fluoroscopy technique.

Conclusion

Based on our relatively new experiences, zero fluoroscopy and TEE guided-only ASD closure is effective and safe in patient with non-complex transcatheter ASD closure in adults. We only used fluoroscopy as bailout strategy in ASD with complex anatomy, pulmonary hypertension and LV systolic dysfunction for hemodynamic assessment purpose.